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32 Minimally Invasive Approaches to Colon and Rectal Diseases: Technique and Best Practices—Pediatrics
363
zone (ATZ), stapled IPAA has been shown to confer no early
advantage with regard to decreased stool frequency or fewer
episodes of fecal incontinence compared to hand-sewn IPAA
[ 29 ]. Despite the results of a large meta-analysis that sug-
gested stapled IPAA offered improved early nocturnal continence with coinciding higher anorectal resting and squeeze
pressures, both procedures are acceptable with different benefi ts [
30 ]. The stapled technique leaves several centimeters
of anorectal mucosa at risk for the development of ulcerative
colitis, polyposis, and in the long run, dysplastic conversion
and malignant degeneration. Most practitioners recommend
routine endoscopic surveillance for this cuff. Since most
pediatric patients have signifi cantly greater life expectancy,
tedious surveillance of this at-risk mucosa can be avoided by
performing a mucosectomy with a hand-sewn ileoanal anastomosis, with a reduced risk of eventual malignancy given
that the life expectancy for these patients is longer.
A trans-abdominal low-anterior dissection of the rectum
can be performed laparoscopically or via the small transverse
suprapubic incision followed by the transanal mucosectomy
on the perineum. For the mucosectomy, a circumferential
incision is made just above the dentate line (Fig. 32.4 ),
and multiple sutures are placed in this mucosal sleeve circumferentially to provide traction (Fig. 32.5 ). Pop- off sutures
are preferred due to their ease of use and identical length.
A Colorado needle-tip Bovie electrocautery is then used to
dissect the muscularis layer proximally off of the mucosal
sleeve (Fig. 32.6 ). At fi rst, the plane can be somewhat diffi cult
to create, but this often becomes easier and more apparent as
the dissection is carried proximally. If the dissection becomes
too facile at this stage, the surgeon may have inadvertently
Fig. 32.5 Rectum and colon pulled down in continuity, bringing
transition zone through the anus ( Courtesy of Keith Georgeson, with
permission )
Fig. 32.4 Mucosal incisions 5–10 mm above the pectinate or dentate
line ( Courtesy of Keith Georgeson, MD, with permission )
Fig. 32.6 Placement of silk traction sutures into the rectal mucosa and
development of the submucosal plane with blunt dissection ( Courtesy
of Keith Georgeson, MD, with permission )
364
E.J. Krebill and D.J. Robertson
Fig. 32.8 Creating the anastomosis of the neoanus
incoming limb to accommodate the stapler. We then close the
common enterotomy with interrupted full-thickness sutures,
to avoid narrowing of the incoming limb with the use of a
Fig. 32.7 Transection of smooth muscle of rectum to join peritoneal
dissection. Transection should begin posteriorly ( Courtesy of Keith
Georgeson, with permission )
stapling device.
Finally, the ileoanal anastomosis is completed by opening
up the apex of the pouch and immediately placing stitches in
four quadrants to fi x it in place followed by intervening
sutures taking big full-thickness bites of the J-pouch and
created a full-thickness dissection instead of remaining in the
submucosal plane. If any defects are created in the mucosal
tube, sutures are placed to repair them. Unfortunately, this
may plicate the mucosa, making it more diffi cult to get back
into the right plane as the proximal dissection continues. Fine,
cotton-tipped swabs can be used as pushers to help create the
plane as well, although small bleeding vessels will require
electrocautery.
healthy bites of the remaining cuff at the dentate line
(Fig. 32.8 ). Given the extent of the pelvic dissection and the
multiple suture/staple lines, we routinely protect the downstream anastomosis with a loop ileostomy. A loop ileostomy
is preferred to a divided end ileostomy to prevent disruption
of any mesenteric infl ow to the J-pouch. We utilize the same
ileostomy site as the end ileostomy which was taken down
for the completion proctectomy.
Once the dissection is carried proximal enough, the muscular cuff itself will evert as depicted in Fig. 32.5 . The muscular
cuff is then incised circumferentially, converting the dissection
Pearls and Pitfalls
to a full-thickness removal of the colon (Fig. 32.7 ). The mus-
cular cuff is usually divided posteriorly and returned back to
the anorectal canal fl at to prevent it from causing obstruction.
If the mesorectum was divided far enough distally in the abdomen the specimen can be freely removed from the fi eld.
Obtaining the extra 5–6 cm of length on the J-pouch
required for the hand-sewn ileoanal anastomosis can be challenging. Care must be taken to preserve enough mesenteric
blood fl ow to the J-pouch from above when dividing the
small sections of mesentery that are often needed to provide
enough length. J-pouch ischemia can also be avoided while
providing extra length by directly incising the peritoneum
over the mesentery. The authors prefer not to open the apex
of the J-pouch until it is through the pelvis and positioned
for the anastomosis. We therefore staple the common wall
between the limbs of the J-pouch from above, opening a
corner of the stapled end, and making an enterotomy on the
– When performing mucosectomy, especially when starting
the dissection, if the dissection seems too easy, the plane
is probably too thick, and the muscle is being left on the
mucosal tube. Adjust the dissection to make the mucosal
tube thinner.
– Ensure that the remaining muscular cuff is divided poste-
riorly and placed smoothly back along the wall of the anal
canal to avoid obstruction of the pouch.
– Although with a stapled IPAA the apex of the J-pouch is
opened to staple the limbs of the J-pouch together, it is
preferable to staple the limbs together from above when
performing mucosectomy. As it is diffi cult in some cases to
get adequate length for hand-sewn IPAA, it is better to provide traction on the apex of the J-pouch prior to opening it
in order to avoid tears at any point of the circumference of
the eventual anastomosis.
32 Minimally Invasive Approaches to Colon and Rectal Diseases: Technique and Best Practices—Pediatrics
patients, but the additional working distance gained from this
Hirschsprung’s Disease
Clinical Presentation and Indications
Hirschsprung’s disease is a developmental disorder of the
enteric nervous system that occurs in one out of 5,000 births
[
31 ]. It is characterized by a failure of ganglion cell migra-
tion through the neural crest during weeks 4–12 of gestation.
This results in a functional obstruction due to a failure of
distal colonic relaxation that is usually confi ned to the rectosigmoid region. The diagnosis should be considered in any
newborn who fails to pass meconium in the fi rst 24–48 h, or
in children suffering from diffi cult bowel movements, poor
feeding, poor weight gain, and progressive abdominal distension. The introduction of laparoscopic-assisted endorectal
pull-through by Dr. Georgeson in the late 1990s revolutionized our surgical approach to this disease in neonates and
young children [ 32 ]. Rarely does Hirschsprung’s disease
remain undiagnosed until adolescence or adulthood but must
be considered in any adult with prolonged, refractory constipation [ 33 ]. A bedside rectal suction biopsy can be performed
in infants less than 10 kg to detect hypertrophic nerve trunks
and the absence of ganglion cells in the colonic submucosa,
confi rming the diagnosis, but not its extent. Older children
and adults require full-thickness rectal biopsy in the operating room. The transition zone may be suggested by barium
enema, but the extent of aganglionosis may be diffi cult to
predict with accuracy, particularly in newborns. Surgical
correction of Hirschsprung’s disease requires removal of the
aganglionic bowel and pull-through of ganglionated bowel
to the level of the anus. Therefore, laparoscopic biopsies can
be extremely useful to identify the proximal extent of
resection.
Surgical Technique: Laparoscopic-Assisted Endorectal Pull-Through
The most frequent pediatric diseases leading to laparoscopic
colectomy and endorectal pull-through include ulcerative
colitis, Hirschsprung’s disease, and familial polyposis syndromes. We will describe the operation for Hirschsprung’s
disease as an example, while the mucosectomy is similar to
that used for pediatric patients with ulcerative colitis.
The patient is positioned transversely at the foot of a shortened operating table with a blanket bump under the body. The
patient’s shoulders are taped to the side of the table where the
feet are located as an extra precaution. The patient is prepped
from the upper abdomen through the toes circumferentially
and covered with an adult extremity drape through which the
infant’s body is passed as demonstrated in Fig. 32.1 .
The fi rst 5-mm radially expanding trocar is placed in the
right mid-abdomen. The umbilicus can be used in larger
port placement in infants is worth the tedious dissection
through the layers of the rectus sheath (picking them up with
hemostats and cutting between them). A left upper quadrant
2.7-mm trocar and a right lower quadrant 2.7-mm trocar are
then placed under direct vision. A fi ne Maryland dissector is
used to grasp a tiny amount of taeniae at the desired site for
biopsy, and a fi ne scissors is used to take a seromuscular
biopsy. After an initial cut, the biopsy is regrasped to lift it
away from the colon, and the scissors are used to push the
underlying mucosa away while taking tangential cuts until
the specimen is free. It is important to angle the scissors
tangential to the bowel to prevent inadvertent penetrance of
the mucosa. Although uncommon, mucosal defects can be
repaired with intracorporeal sutures. Biopsies are sent for
frozen section to determine the level at which normal numbers of ganglion cells are present. Ideally, no biopsies will
have been taken proximal to this level. In the 10 % of patients
that do have long-segment Hirschsprung’s disease, the colon
can be mobilized laparoscopically for a pull-through as well.
In patients with total colonic Hirschsprung’s, we recommend
waiting for permanent biopsies to confi rm the diagnosis.
The appendix can also be a useful biopsy to look for ganglion cells. We prefer to wait to perform a pull-through in
these patients and instead perform ileostomy after the level
of ganglion cells is confi rmed (the aganglionosis can extend
into the small bowel). A laparoscopic Duhamel procedure
(i.e., leaving the aganglionic rectum in place and performing
a retrorectal anastomosis with the rectum and normally
innervated bowel) is then performed around 9 months of age,
the technical details of which are described elsewhere.
After the level of normal, ganglionated bowel is defi ned by
biopsy, laparoscopic division of the mesentery of the bowel to
be resected is performed (Fig. 32.9 ). A Foley catheter placed
on the sterile fi eld may be required to decompress the bladder
for a better view into the pelvis. Hook electrocautery works
well to divide the mesentery in infants staying close to the
colon and away from the retroperitoneum. The white line of
Toldt can be mobilized if needed for extra length of the pullthrough as well. Mucosectomy, as described in the above section on ulcerative colitis, is then performed. After the release
of pneumoperitoneum, the infants’ feet are wrapped in Kerlix
and clipped to the drape above the head effectively placing
the patient in dorsal lithotomy. Silk sutures are used to evert
the anus and mucosectomy is then performed. The muscular
cuff everts nicely after this dissection in infants and it can
then be divided (Fig. 32.10 ). After the muscular cuff is
divided, the specimen will typically drop out of the anorectal
canal (Fig. 32.5 ). A marking suture at the level of the biopsy
showing ganglion cells can be useful to determine where to
make the anastomosis. If possible, the anastomosis should be
performed proximal to the biopsy site to prevent problems
from being too close to the transition zone. The anterior wall
of the anastomosis is created fi rst prior to completely dividing
365
366
E.J. Krebill and D.J. Robertson
Fig. 32.9 Anatomic depiction of the colorectal mesentery divided
during the laparoscopic dissection of an endorectal pull-through
operation ( Courtesy of Keith Georgeson, with permission )
Fig. 32.10 Eversion of the muscular cuff after mucosectomy in an
infant undergoing pull-through for Hirschsprung’s disease
the specimen. It is recommended to send the margin of the
resected pull-through for a larger confi rmatory frozen section
biopsy. Figure 32.11 depicts the completed anastomosis with
the resected pull-through segment passed off the fi eld.
Pearls and Pitfalls
– Mobilizing the mesentery of the sigmoid colon laparo-
scopically going into the pelvis greatly facilitates removal
of the specimen from below. The specimen will literally
drop right out of the anal canal.
– Ensure adequate mobility of the colon into the pelvis lap-
aroscopically prior to commencing with perineal dissection. This often involves mobilizing the white line of
Toldt and sometimes even the splenic fl exure.
– In long-segment Hirschsprung’s disease, it is valuable to
await fi nal pathology prior to committing to an extensive
colectomy. Laparoscopic biopsies allow this without
having to start with a perineal dissection. Even with experienced pediatric pathologists, calling ganglion cells on
small samples by frozen section can be diffi cult.
– Try to create the anastomosis proximal to your last biopsy
that showed ganglion cells to avoid problems with the
transition zone.
– Always send the margin of the pull-through at the level of
the anastomosis for frozen section to reconfi rm that there
are ganglion cells present.
Fig. 32.11 Securing neorectum to short anorectal cuff ( Courtesy of
Keith Georgeson, with permission )
Anorectal Malformations or Imperforate Anus
Anorectal malformations describe a wide spectrum of defects
in the development of the lower intestinal and urogenital
tracts. An imperforate anus is usually discovered shortly
after birth. While this term may accurately depict the patient’s
outward appearance, the malformation can involve a number
of different but predictable patterns of fi stulous connections
between the rectum and urogenital structures or perineum.
This created signifi cant challenges for early pediatric surgeons
32 Minimally Invasive Approaches to Colon and Rectal Diseases: Technique and Best Practices—Pediatrics
367
as they attempted to repair these defects using a combination
of abdominal, sacral, and perineal incisions. Today, the surgeon must determine which children should undergo primary
repair in the neonatal period and which children require
colostomy and defi nitive repair in a staged fashion. In 1982,
Peña et al. reported the results of the modern open approach
referred to as the posterior sagittal anorectoplasty (PSARP)
or posterior sagittal anorectovaginourethroplasty (PSARVUP)
[
34 ]. Nearly two decades later, Georgeson et al. described the
novel laparoscopically assisted anorectal pull-through
(LAARP) for repair of high imperforate anus, utilizing minimal perineal dissection, preservation of the distal rectum, and
accurate placement of the rectum within the levator ani and
external anal sphincter muscle complex [ 35 ].
Surgical Technique: Laparoscopic-Assisted Anorectal Pull-Through (LAARP)
A colostomy should be performed within 24–48 h of birth in
children with complex malformations often grouped together
as “high imperforate anus.” These include rectourinary
fi stula in boys and rectovaginal fi stula or cloaca in girls.
Rectovestibular fi stulas in girls are inside the vaginal introitus, but exterior to the hymen. Some pediatric surgeons
repair this primarily with a perineal anoplasty, but the common wall between the vagina and rectum can be extensive, as
can the dissection. Colostomy is often performed for this
type as well. Defi nitive repair is then performed at 2–3
months of age. When creating the colostomy, the distal
descending colon is divided at the junction with the sigmoid
to maintain as much length as possible for the subsequent
pull-through operation. A mucous fi stula is also created.
Subsequent contrast studies via this mucous fi stula can help
defi ne the anomalous connections to the urethra or bladder in
boys and to the vagina in girls. No fi stula may be present in
patients with trisomy 21. Loop colostomy is discouraged due
to the possibility of spillover and the risk for urinary tract
infection in those with urinary fi stulae.
LAARP is most useful in boys with rectourinary fi stulas,
although the authors have used it in females with no fi stula
and trisomy 21. In most females with high imperforate anus,
the anatomy requires the open PSARP approach. For
LAARP, the patient is positioned similar to that described in
the above section on Hirschsprung’s disease. Laparoscopic
trocar placement is identical (Fig. 32.12 ). A Foley is placed
sterilely on the fi eld and left in place for 1 week postoperatively in those with urinary fi stulas. The mucous fi stula is
located and dissection of the sigmoid colon is carried into the
pelvis (Fig.
to the rectourethral fi stula (Fig.
32.13 ). Care is taken to preserve the mesorectum
32.14 ). Typically, there is
considerable narrowing of the rectum as it gets closer to the
urinary tract (Fig.
32.15 ). The surgeon must also be able to
Fig. 32.12 Incising the peritoneum to enter the pelvis to dissect out the
rectum circumferentially. Note the position of the vas deferens which
need to be preserved as dissection approaches the urethra
Fig. 32.13 The rectum will extend toward the urethra anteriorly as dissection gets deep in the pelvis
recognize and avoid injury to adjacent structures, including
the ureters, vas deferens, and prostate depending on the level
of the fi stula. A fourth trocar is placed to provide traction on
the fi stula out of the pelvis for fi stula ligation. It is important to
ligate and divide the fi stula close to the urethra (or bladder)
to avoid leaving excess colonic mucosa on the stump
(Fig. 32.16 ). This has been known to cause mucocele formation. While reports of post-LAARP complications are rare, a
pediatric surgery group in Japan recommends routine MRI
during follow-up to identify residual fi stulae or cystic formations [
37 ]. The authors ligate the fi stula with silk ligatures
and cut between them, although the use of clips has been
described. In a very low fi stula to the urethra at the level of
the pelvic fl oor, the authors used a stapling device successfully. Endoloops (Ethicon Endo-Surgery, Cincinnati, OH)
368
E.J. Krebill and D.J. Robertson
Fig. 32.14 The rectum has been passed down to the perineum. This
laparoscopic view demonstrates no twisting as it enters the pelvis
Fig. 32.15 The actual rectourethral fi stula often tapers down and becomes
narrower at the junction with the urethra
can be used as well, but only after division of the fi stula.
Without traction on the rectum, after division the fi stulous
connection retracts deep into the pelvis making placement of
the Endoloops more challenging.
After division of the fi stula, the patient is placed into
dorsal lithotomy (see section “Hirschsprung’s Disease” for
positioning). A Peña muscle stimulator is used to locate the
point of maximal contraction of the external anal sphincter.
A 12-mm skin ellipse is removed from this area in the midline
on the perineum. While watching the pelvic fl oor laparoscopically (a quite unique view with no rectum in the pelvis),
a 12-mm Step™ trocar sheath and a Veress needle are
inserted between the two limbs of the puborectalis muscle in
the midline and into the pelvis (Fig. 32.16 ). The trocar is
placed through the sheath. The distal rectum is grasped with
Fig. 32.16 Anteriorly note the small stump of the fi stula. Posteriorly the
sheath from a trocar can be seen placed into the pelvis in the midline
Fig. 32.17 A completed anastomosis at the neoanus
a laparoscopic grasper and brought out onto the perineum. If it
will not pass through the canal made by the trocar, a large
hemostat can be inserted through the tract instead and gently
used to guide the rectum down to the perineum. A circumferential, single-layer anastomosis is then made between the
distal rectal fi stula and the dermis to create the neoanus
(Fig. 32.17 ). The rectum can be grasped laparoscopically
and retracted cephalad to deepen the anal dimple and
lengthen the skin-lined portion of the anal canal.
Early postoperative studies have noted more favorable
anorectal manometry fi ndings and reliable indicators of
potential continence in patients repaired with laparoscopicassisted technique compared to PSARP. There is signifi cantly
earlier detection of a rectoanal relaxation refl ex, lower resting
rectal pressure, and improved rectal compliance in patients
32 Minimally Invasive Approaches to Colon and Rectal Diseases: Technique and Best Practices—Pediatrics
369
who underwent LAARP [ 36 ]. This translates to satisfactory
defecatory function for patients with high or intermediatetype imperforate anus after LAARP that is at least as good as
PSARP results [ 38 ]. Additional benefi ts of LAARP include
shorter hospital stays and lower rates of rectum malposition
based on magnetic resonance imaging [ 39 ].
Pearls and Pitfalls
– When dividing the rectourethral fi stula, ensure that the
division is as close to the urethra as feasible, in order to
prevent postoperative mucocele.
– Take care as the deep pelvic dissection commences to
watch for and avoid injury not only to the ureters but also
to the vas deferens and seminal vesicles as the urethra is
approached.
Fecal Incontinence
Many pediatric patients born with anorectal malformations,
Hirschsprung’s disease, spinal anomalies, and other congenital anomalies suffer from fecal incontinence that negatively impacts their emotional and social development. The
goals of standard, nonsurgical management are to achieve
regular bowel habits and stool consistency with a combination of diet modifi cation, medication, and routine enemas
to promote regular colonic emptying. Daily rectal enemas
are easily administered in infants, but many children
become intolerant or noncompliant. Historically, a diverting colostomy was necessary when nonoperative treatment
failed, in which case the family is burdened with stoma care
and the child incurs the additional social stress of having an
ostomy. A permanent indwelling cecal tube can also be
used to provide antegrade enemas at convenient times to
fl ush out the colon. This is superior to enemas from below
which may only partially evacuate the colon. The goal is to
perform regular fl ushes at convenient times, which usually
have rapid results, and to avoid incontinent “accidents”
between fl ushes. Most patients are highly satisfi ed with
antegrade enemas, and with titration, most can eliminate
nearly all episodes of incontinence. The authors recommend titration to effect starting with a mixture of 100 ml of
tap water and 20 ml of glycerin. Most patients fl ush once
daily with success. Too much glycerin can result in
cramping.
An alternative surgical procedure for fecal incontinence
was introduced by Malone in 1990 [ 40 ]. He described a
method in which the appendix is used as a conduit to administer an antegrade continence enema (ACE). In some patients
who have undergone previous appendectomy, a neo- appendix
can be fashioned with a tubularized cecal fl ap. Both have the
advantage of creating a catheterizable channel so the patient
does not require a permanent indwelling tube. The appendix
is typically long enough and pliable enough that leakage is
rare when the catheter is not stenting it, and most patients
simply wear a Band-aid
®
or other adhesive bandage over the
stoma between fl ushes. We prefer to bring the appendix up to
the base of the umbilicus in most patients to hide it. In obese
patients (some of whom are wheelchair bound), catheterizing deep in the umbilicus can be challenging, and alternative
sites on the abdominal wall can be used, such as the right
lower quadrant.
We only offer this procedure in patients who are emotionally and socially mature enough to voluntarily participate in
the daily catheterizations.
Surgical Technique: Laparoscopic-Assisted Appendicostomy
Trocar placement is identical to that described for laparoscopic appendectomy except a 10-mm trocar is placed at the
umbilicus instead of a 12-mm trocar. The cecum and right
colon are mobilized laterally so that the appendix tip will
easily reach the umbilicus. Care is taken to preserve the
mesoappendix. The appendiceal tip is then grasped with a
laparoscopic trocar through the 10-mm trocar site, and the
appendix is brought up to the umbilical skin, backing out the
trocar in the process. Forceps are used to stabilize the appendix. Two 4–0 sutures are used to secure seromuscular bites of
the appendix to the fascia. The tip of the appendix is excised
with electrocautery, and a 10-Fr or 12-Fr Foley catheter is
inserted all the way into the appendix prior to infl ating the
balloon which is drawn back to rest in the cecum at the
appendiceal orifi ce. Circumferential 4–0 sutures are used to
secure the appendiceal opening to the dermis. The Foley is
secured with a suture to the skin to prevent inward migration,
and the Foley itself is typically kept in for 4–6 weeks while
the site heals. Small fl ushes daily are used to maintain
patency for the fi rst 2 weeks after which daily therapeutic
fl ushes commence. The Foley can be removed after 4–6
weeks, but daily catheterization is required to prevent stricture formation at the skin level which is reported to occur in
up to 20 % of patients. Some surgeons have reported using
an umbilical V-Y appendicoplasty technique to decrease
stricture rate, although we have found that daily compliance
with an ACE program is most helpful in preventing this
problem.
Pearls and Pitfalls
– Patients must catheterize the channel every single day to
minimize the risk of stomal stricture formation
370
Summary
Minimally invasive surgery has now become almost universally a part of most pediatric surgery practices, and there are
many applications in colorectal surgery. Smaller instrumentation and more widespread training for pediatric surgical
techniques have been the primary factors in this development. The literature still lacks, and desperately needs, large,
well-conducted prospective trials comparing laparoscopic
with traditional open procedures to validate the presumed
benefi ts of MIS. The appeal of smaller incisions, shorter hospital stays, and more rapid return to preoperative activities
will continue to serve as the catalyst for the continued development of MIS.
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Laparoscopy in Pregnant Patients
Melissa M. Alvarez-Downing and David J. Maron
33
K e y P o i n t s
• Laparoscopy can be performed safely in pregnancy.
• When addressing abdominal pain during pregnancy, the
patient should be managed similarly to the nonpregnant
patient.
• Consideration of the age of gestation and size of the
gravid uterus is necessary to determine adequate port
placement and surgical approach.
• Utilizing a strategy of expectant management is dangerous
to the pregnant patient and fetus and should be avoided.
Introduction
Approximately 1 in 500 to 1 in 635 women will require
non- obstetrical abdominal surgery during pregnancy [ 1 , 2 ].
While the most common non-obstetrical surgical emergencies include acute appendicitis, cholecystitis, and bowel
obstruction, a wide range of operations performed in pregnancy have been reported.
The traditional approach to abdominal surgery during
pregnancy has been via laparotomy in order to avoid injury
to the gravid uterus and fetus. It was initially believed that
laparoscopy was unsafe in pregnancy due to risks of CO
insuffl ation and instrumentation. Yet, as laparoscopy has
gained popularity and experience, recent evidence has contradicted this initial belief and has shown that laparoscopy is
indeed a safe surgical approach for a variety of conditions in
the pregnant patient [
regarding laparoscopy in pregnancy pertains to appendicitis
Electronic supplementary material Supplementary material is available
in the online version of this chapter at
Videos can also be accessed at
videos/978-1-4939-1580-4
M. M. Alvarez-Downing , M.D. • D. J. Maron , M.D., M.B.A. (*)
Department of Colorectal Surgery , Cleveland Clinic Florida ,
2950 Cleveland Clinic Boulevard , Weston , FL 33331 , USA
marond@ccf.org
e-mail:
3 – 5 ]. While most of the literature
10.1007/978-1-4939-1581-1_33 .
http://www.springerimages.com/
.
2
and cholecystitis, a few accounts of its use in the management
of colorectal diseases have been reported [
when managing abdominal pain in the pregnant patient, the
guiding principle is prompt diagnosis and treatment, which
results in improved fetal outcome [ 6 , 7 ].
4 ]. Overall,
Overview of Changes in Physiology and Anatomy During Pregnancy
The physiologic changes that occur in pregnancy involve
nearly every organ system of the expectant mother (Table 33.1 ).
These changes, which occur slowly over time, are a response to
the growing fetus and an internal shift of support, cumulatively
accounting for drastic changes to the pregnant patient.
The cardiovascular system is affected by an increased
plasma blood volume of 40–50 %. This triggers an augmented
stroke volume and a 50 % increase in cardiac output [ 8 ].
Circulating increased progesterone levels cause a decrease in
systemic vascular resistance and subsequent lower blood pressure with an increased heart rate by an average of 15 beats per
minute. Additionally, there is a 20–30 % increase in red blood
cell volume, which combined with increased plasma blood
volume causes a purely dilutional decrease in the patient’s
hematocrit. Furthermore, increased hepatic production of
coagulation factors causes a hypercoagulable state, which in
addition to decreased activity can result in a signifi cant risk
for developing blood clots and emboli.
Changes in the respiratory system during pregnancy also
take place. The enlarging uterus displaces the diaphragm
cephalad and increases intra-abdominal pressure [ 9 ]. To
compensate, relaxation of the rib-cage ligaments occurs with
a resultant increase in chest wall size. While the total lung
capacity (TLC) remains the same in pregnancy, there is a
20–30 % decrease in functional residual capacity (FRC) and
its components: expiratory reserve volume (ERV) and residual volume (RV). A compensatory increase in inspiratory
capacity (IC), through a 30–50 % increase in tidal volume
(Vt), maintains the TLC. This maintenance of lung capacity
H.M. Ross et al. (eds.), Minimally Invasive Approaches to Colon and Rectal Disease: Technique and Best Practices,
DOI 10.1007/978-1-4939-1581-1_33, © Springer Science+Business Media New York 2015
373